What are tests for? The implications of stuttering steps along the US patient pathway.

This article explores the implications of how US family physicians make decisions about ordering diagnostic tests for their patients. Data is based on a study of 256 physicians interviewed after viewing a video vignette of a presenting patient. The qualitative analysis of 778 statements relating to trustworthiness of evidence for their decision making, the use of any kind of technology and diagnostic testing suggests a range of internal and external constraints on physician decision making.

Prevalence and overlap of childhood and adult physical, sexual, and emotional abuse: a descriptive analysis of results from the Boston Area Community Health (BACH) survey.

Abuse is associated with a wide variety of health problems, yet comprehensive population-based data are scant. Existing literature focuses on a single type of abuse, population, or lifestage. Using a racially/ethnically diverse community-based sample, we document the prevalence of physical, emotional, and sexual abuse by lifestage and gender, assess variation in abuse by sociodemographics; establish overlap of abuses; and examine childhood abuse relationships with abuse in adulthood.

Physician styles of patient management as a potential source of disparities: cluster analysis from a factorial experiment.

Objective: To identify styles of physician decision making (as opposed to singular clinical actions) and to analyze their association with variations in the management of a vignette presentation of coronary heart disease (CHD).

Data Source: Primary data were collected from primary care physicians in North and South Carolina.

Study Design: In a balanced factorial experimental design, primary care physicians viewed one of 16 (2(4)) video vignette presentations of CHD and provided detailed information about how they would manage the case.

Gendered uncertainty and variation in physicians' decisions for coronary heart disease: the double-edged sword of "atypical symptoms".

Nonmedical factors and diagnostic certainty contribute to variation in clinical decision making, but the process by which this occurs remains unclear. We examine how physicians' interpretations of patient sex-gender affect diagnostic certainty and, in turn, decision making for coronary heart disease. Data are from a factorial experiment of 256 physicians who viewed 1 of 16 video vignettes with different patient-actors presenting the same symptoms of coronary heart disease.

Influences of organizational features of healthcare settings on clinical decision making: qualitative results from a cross-national factorial experiment.

A proliferating literature documents cross-national variation in medical practice and seeks to explain observed differences in terms of the presence of certain kinds of healthcare systems, economic, and cultural differences between countries. Less is known about how providers themselves understand these influences and perceive them as relevant to their clinical work. Using qualitative data from a cross-national factorial experiment in the United States and United Kingdom, we analyze 244 primary care physicians' explanations of how organizational features of their respective healthcare settings influence the treatment decisions they made for a vignette patient, including affordability of care; within-system quality deficits; and constraints due to patient behavior.

Examining critical health policy issues within and beyond the clinical encounter: patient-provider relationships and help-seeking behaviors.

Among notable issues in health care policy and practice over the past 50 years have been those centered on the changing dynamics in clinical encounters, predominantly the relationship between physicians and patients and access to health care. Patient roles have become more active, diverse, long-term, and risk-based, while patient-provider relationships are multifaceted, less paternalistic, and more pivotal to health outcomes. Extensive literatures on help-seeking show how much social influences affect both undertreatment and inappropriate high utilization of health care.

Swapping horses midstream: factors related to physicians' changing their minds about a diagnosis.

Purpose: Premature closure has been identified as the single most common cause of diagnostic error. This factorial experiment explored which variables exert an unconfounded influence on physicians' diagnostic flexibility (changing their minds about the most likely diagnosis during a clinical case presentation).

Method: In 2007-2008, 256 practicing physicians viewed a clinically authentic vignette simulating a patient presenting with possible coronary heart disease (CHD) and provided their initial impression midway through the case.

Physician cognitive processing as a source of diagnostic and treatment disparities in coronary heart disease: results of a factorial priming experiment.

Literature on health disparities documents variations in clinical decision-making across patient characteristics, physician attributes, and among health care systems. Using data from a vignette-based factorial experiment of 256 primary care providers, we examine the cognitive basis of disparities in the diagnosis and treatment of coronary heart disease (CHD). We explore whether previously observed disparities are due to physicians (1) not fully considering CHD for certain patients or (2) considering CHD but then discounting it.

What do physicians gain (and lose) with experience? Qualitative results from a cross-national study of diabetes.

An empirical puzzle has emerged over the last several decades of research on variation in clinical decision making involving mixed effects of physician experience. There is some evidence that physicians with greater experience may provide poorer quality care than their less experienced counterparts, as captured by various quality assurance measures. Physician experience is traditionally narrowly defined as years in practice or age, and there is a need for investigation into precisely what happens to physicians as they gain experience, including the reasoning and clinical skills acquired over time and the ways in which physicians consciously implement those skills into their work.

Disparities in physicians' interpretations of heart disease symptoms by patient gender: results of a video vignette factorial experiment.

Background: Previous studies have documented the underdiagnosis of coronary heart disease (CHD) in women, but less is known about which alternate diagnoses take precedence and whether additional patient factors modify possible gender bias.

Objective: To measure gender variation in clinical decision making, including (1) the number, types, and certainty levels of diagnoses considered and (2) how diagnoses vary according to patient characteristics, when patients have identical symptoms of CHD.

Methods: This was a factorial experiment presenting videotaped CHD symptoms, systematically altering patient gender, age, socioeconomic status (SES) and race, and physician gender and level of experience.

Do physicians attend to base rates? Prevalence data and statistical discrimination in the diagnosis of coronary heart disease.

Objective: To examine whether physicians attend to gender prevalence data in diagnostic decision making for coronary heart disease (CHD) and to test the hypothesis that previously reported gender differences in CHD diagnostic certainty are due to discrimination arising from reliance on prevalence data ("statistical discrimination").

Data Sources: A vignette-based experiment of 256 randomly sampled primary care physicians conducted from 2006 to 2007.

Study Design: Factorial experiment.

The decision to intensify therapy in patients with type 2 diabetes: results from an experiment using a clinical case vignette.

Purpose: Lack of medication intensification is a widely recognized but poorly understood barrier to effective diabetes care. We used a video case vignette to assess whether patient or physician demographic variables influence the decision to intensify therapy.

Methods: One hundred ninety-two US primary care physicians each viewed one case vignette of an actor portraying a patient who had type 2 diabetes and borderline indications for medication intensification.

What happens along the diagnostic pathway to CHD treatment? Qualitative results concerning cognitive processes.

Extensive research on health disparities documents persistent differential diagnosis and treatment of many conditions according to patient characteristics, physician attributes, and healthcare systems. Less is known about how physicians arrive at their decisions. We use qualitative data from a vignette-based factorial experiment to examine how physicians reason through and account for their clinical decisions, and how variations arise despite the presentation of identical symptoms of coronary heart disease (CHD).

Physician clinical information technology and health care disparities.

The authors develop a conceptual framework regarding how information technology (IT) can alter within-physician disparities, and they empirically test some of its implications in the context of coronary heart disease. Using a random experiment on 256 primary care physicians, the authors analyze the relationships between three IT functions (feedback and two types of clinical decision support) and five process-of-care measures. Endogeneity is addressed by eliminating unobserved patient characteristics with vignettes and by proxying for omitted physician characteristics.

Diagnostic certainty as a source of medical practice variation in coronary heart disease: results from a cross-national experiment of clinical decision making.

The authors examined physician diagnostic certainty as one reason for cross-national medical practice variation. Data are from a factorial experiment conducted in the United States, the United Kingdom, and Germany, estimating 384 generalist physicians' diagnostic and treatment decisions for videotaped vignettes of actor patients depicting a presentation consistent with coronary heart disease (CHD). Despite identical vignette presentations, the authors observed significant differences across health care systems, with US physicians being the most certain and German physicians the least certain (P < 0.

How are patient characteristics relevant for physicians' clinical decision making in diabetes? An analysis of qualitative results from a cross-national factorial experiment.

Variations in medical practice have been widely documented and are a linchpin in explanations of health disparities. Evidence shows that clinical decision making varies according to patient, provider and health system characteristics. However, less is known about the processes underlying these aggregate associations and how physicians interpret various patient attributes.

Is certainty more important than diagnosis for understanding race and gender disparities?: an experiment using coronary heart disease and depression case vignettes.

Objectives: To (1) examine the influence of patient and provider attributes on physicians' diagnostic certainty and (2) assess the effect of diagnostic certainty on clinical therapeutic actions.

Methods: Factorial experiment of 128 generalist physicians using identical clinically authentic videotaped vignettes depicting patients with coronary heart disease (CHD) or depression.

Results: For CHD, physicians were least certain for Black patients (p=.

Prevalence and correlates of sexual activity and function in women: results from the Boston Area Community Health (BACH) Survey.

Relatively few studies have measured sexual functioning in women using a large, diverse, community-based sample with measures that allow for direct comparisons with previous findings. In this article, we: (1) describe prevalence of sexual activity in women by key sociodemographic characteristics, including age, race/ethnicity, marital status, and socioeconomic status; and (2) estimate the influence of key correlates on sexual problems. Data were analyzed from the Boston Area Community Health (BACH) Survey, a 2002-2005 community-based epidemiologic study of urologic and gynecologic symptoms, sociodemographics, health status, and psychosocial characteristics in a diverse sample of Boston area residents (N = 3,205 women aged 30-79 years).

An examination of the association of abuse (physical, sexual, or emotional) and female sexual dysfunction: results from the Boston Area Community Health Survey.

Objective: To examine associations between abuse (physical, sexual, and emotional) in childhood and adolescence/adulthood and sexual activity and dysfunction in women.

Design: We analyzed data from the Boston Area Community Health Survey, a community-based epidemiologic study of urologic and sexual symptoms and risk factors in a racially and ethnically diverse random sample of women aged 30-79 years (N = 3,205 women).

Setting: Boston area community.

Using focus groups to improve the validity of cross-national survey research: a study of physician decision making.

In this article, the authors demonstrate how qualitative methods can form a foundation for quantitative research by improving instrument validity, informing the data collection process, and improving cost-effectiveness in a study of physician decision making. To test terminology, applicability, and comprehension of a quantitative questionnaire for doctors in the United States and United Kingdom, each country's researchers conducted physician focus groups with questions organized around the experiment, including (a) validity of video vignettes of actor "patients," (b) population accessibility, (c) level of remuneration, (d) appropriate endorsement figure, and (e) question comprehension. Focus group data collected during instrument development and fieldwork planning streamlined processes and achieved cost efficiencies and effectiveness for the overall study.

Is abuse causally related to urologic symptoms? Results from the Boston Area Community Health (BACH) Survey.

Objectives: We investigated (1) whether sexual, physical, or emotional abuse experienced either as a child or as an adolescent/adult is associated with symptoms of urinary frequency, urgency, and nocturia, and (2) the extent to which the observed association between abuse and urologic symptoms may be causal.

Methods: Analyses are based on data from the Boston Area Community Health (BACH) survey, a community-based epidemiologic study of many different urologic symptoms and risk factors. BACH used a multistage stratified cluster sample to recruit 5506 adults, aged 30-79 yr (2301 men, 3205 women; 1770 black [African American], 1877 Hispanic, and 1859 white respondents).

How do doctors in different countries manage the same patient? Results of a factorial experiment.

Objective: To determine the relative contributions of: (1) patient attributes; (2) provider characteristics; and (3) health care systems to health care disparities in the management of coronary heart disease (CHD) and depression.

Data Sources/study Setting: Primary experimental data were collected in 2001-2 from 256 randomly sampled primary care providers in the U.S.

Ambiguities of chronic illness management and challenges to the medical error paradigm.

In recent decades, an interdisciplinary quality assurance (QA) movement has emerged in health care studies, which has included increased attention to medical errors. Implicit in this QA effort is a conflict between (1) external agents encouraging the medical profession to adopt strategies for reducing errors and (2) sociological characteristics of medical practice that systematically inhibit the uptake of these strategies. Using interviews with providers and observations in two diabetes clinics in a large Midwestern city in the USA, we examine how providers understand error in their work, as well as how they think about failures in care and efforts to standardize and impose guidelines in care.